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FOR OFFICE USE: APPLICATION FPR A.NITATION PERMIT �.... ..�-•--�--•- --..-..-• ` �lete in Tri,p Permit No. ....... ....... .... . .......... ........ (Com licate) ................................_......----............. This Permit Expires 1 Year From bate Issued �..r:..:�... Date Issued ... Application is hereby made to the,San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations- 'AS;' egulations: JOB ADDRESS/LOCATION .--. S`:�.....2 ...._....-----•--------•-_-. • ..............CENSUS TRACT .......................... Owner's Name .�. .- - TBS 0 8 ........ PhoneT05.9.0.2 Address .r)SC�"..._. .. City ..... ....... .....••-----......... -----.......---•--....._.........._. .-- - -- ----- .............................................---..License # ... ---.............--.. Phone ....----•-............-------- Contractor s Name .... Installation will serve: ResidenceVApartment House,❑ Commercial ❑Trailer Court Motel ❑Other ............. --------- ------------ i i Number of living units:..` Number of bedrooms A-.-Garbage Grinder tot Size ..:.. �.�.��..-° `....... . _ Water Supply: Public System and 'name . 4n-s2�-------------------------------------- _....Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe X Fill Moterial ............ If yes, type (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic nk or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] EPTIC TANK ] Size.......---------•--------------__.............. Liquid Depth d Capacity Q1)G,o Type ........--•-•-• -,. Material.................-... No. Compartments ................ ......� Distance "to nearest: Well .......,.,-Foundation ....___.............. Prop. Line ............... ._.---- LEACHING LINE [ ] No. of Lines Length of each line ...- Total length ............. 'D' Box ..If.. ... - Type Filter Material ........ ...........Depth Filter Material Distance to nearest: Well ------------------------ Foundation . _. ................. Property Line ..------------------._..� SEEPAGE PIT [ [ Depth .. .� .. Diameter --------------- Number Rock Filled Yes ❑ No ❑� Water Table Depth ............. ..........................Rock Size ---------_------........ � Distance to nearest: Well ........___------------------------.Foundation ........ ........... Prop. Line .............. I .i REPAIR DDITION(Prev. Sanitation Permit# ............_._....___.._.... ------------ Date ---- ------- ic Tank (Specify Requirements) - - -- ----- ------o----- ---_--------------- ........ .....;X ---------------------------- . -.-.-.-.-.---.....-.. Disposal Field (Specify Requirements) ^ `'.. ............. - . (Draw existing and required ............. ........ addition on reverse side) I hereby certify that I have prepared this application and that the work will be done irk accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen. sed agents signature certifies the following: "I certify that in the performance .of the work for which this permit is issued, I shall not employ any person in such manner as to becom"ub'ect toW rkma s Compensation laws of California." Signed)c _ .. ..- ./: ------------------•-------------- Owner By . Title (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... -.,k.. -- -- .---------. DATE ...... -•.3.... .. ................. BUILDING PERMIT ISSUED --- ----- :.... ..................................... ADDITIONAL COMMENTS .... . ........ . ....rstrvK�l__._ e.._..-. W ---- ..............•---....... ------............ : - .. .. ::::: : :: ........:. . Final Inspection by: ..--... . .. -- ---1--------._....- •- •-----------------Date ............._..:: .. ,o SAN JOAQUIN LOCAL HEALTH DISTRICT H_ . E. Z3 241.'fiE (%ev_ 5M_. - 7172 3 X. .„-